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                                                                         *63912191W*

           Illinois Department of Revenue                                                                                        Year ending

                                                                   Income Received
           Schedule I                                                                                                            Month                     Year
           Attach to your Form IL-1041.                                                                                          IL Attachment No. 8

Enter your name as shown on your Form IL-1041.                           Enter your federal employer identification number (FEIN).

Identify the entities from whom you received income 
           A                                                             B                                                                                     C
           Name and address                                              FEIN                                                                              Type
                                                                                                                                 (See instructions)

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                                          This form is authorized as outlined by the Illinois Income Tax Act. Disclosure of this 
           Schedule I (IL-1041) (R-12/19) information is REQUIRED. Failure to provide information could result in a penalty.     Printed by the authority of the State
                                                                                                                                 of Illinois - web only, 1 copy
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